The Uganda Report

I have been very fortunate to have spent the week with the Clinton Health Access Initiative (CHAI) team in Kampala on a knowledge/ideas exchange visit. The visit was made possible because of a mutual interest in access to ORS and Zinc for diarrhoea treatment and a lot of goodwill on the part of several people. Barty, the Private Sector Programmes Manager here, and I met in London a while before either of us were involved in this business and so have maintained contact. In addition, the head of CHAI in Zambia who is a big supporter of ColaLife (and a member of our Steering Committee) has ensured that the other CHAI country heads know what we are doing.

Anyway, this was a bit like David meeting Goliath. CHAI is huge with a huge and well earned reputation for their work on improving access to essential medicines. They made their name from the global level negotiations backed up by the the brilliant supply and demand forecasting work they did to convince the pharmaceutical industry to collaborate and massively reduce the price of ARVs for the treatment of HIV/AIDS and ACTs for the treatment of malaria. Their work has led to vastly improved access to medicines for HIV/AIDS and malaria patients, contributing to a reduction in mortality rates from both of these devastating diseases

CHAI’s work has helped turn HIV/AIDS from being a death sentence, to a chronic, manageable disease.

While CHAI’s work on HIV/AIDS continues, they have turned their attention to the accessibility of other essential health products and services including ORS and Zinc for the treatment of diarrhoea in under 5 children.

It was clear from the outset what I was going to get out of this trip but what was ColaLife going to be able to contribute?

Barty set me up with meetings with all the key people I needed to see and these included:

So what was I able to contribute? Well fortunately, although CHAI has already done a lot of work on the supply side of ORS and Zinc to Uganda – building on their approach and experience in ARVs and ACTs – their work on product development is only just beginning and this is our strength. So my visit kicked off with a great meeting with Emilie, CHAI’s Head of Innovation for ORS and Zinc before she dashed off to visit ORS and Zinc manufacturers in India, where I was able to share our learning from the trial particularly in the area of small ORS sachets and use of the packaging as a measuring, mixing and storage device and cup.

But I think, the biggest contribution I made to all the meetings was the injection of a bit of inspiration and excitement around the Kit Yamoyo product. Talking about ORS and Zinc in abstract can be a pretty dull process but if you put an aspirational product in front of people the whole tone of the conversation changes. It may be that the current Kit Yamoyo configuration isn’t the right one for Uganda but it gives people something to touch and feel and get excited about. All of a sudden people can see why small sachets are important in a way that they didn’t perhaps appreciate before. This was a feature of all the meetings I participated in and this was very rewarding. However, there is a sharp focus on price here and that comes with some concern about the price. Kit Yamoyo will always be more expensive than 2 one litre sachets of ORS and a blister pack on Zinc in a cardboard box.

This whole trip was made even more enjoyable and productive by our virtual advisory board member Dr Beth Anne Pratt who has returned to live in Uganda (from Zambia) and was able to set the scene for me (and meet from the airport and put me up on my first night). Beth and I have had some great discussions about cost, price, willingness to pay and product desirability. I’ll had over to her to summarise some of these discussions. She’s American so please excuse the spelling 🙂

This is the first time people have seen a combined ORS+Zinc+Measure kit. It gave people something not only to visualize, but also to begin assessing and discussing the meaning of “value” (in the broadest sense of the word). Presenting the kit gives stakeholders not only lessons to build on but, most importantly, something to talk about besides just “cost”.

Suddenly, design, desire, and appropriateness can be built into discussions of price elasticity. Because price elasticity – in a big picture sense as opposed to a purely economics sense – is not simply about price increase/decrease vs. and willingness/ability to pay. There are all these intangible cultural, social, political, and individual factors that feed into the decisions people make about purchasing a product…especially a product such as medicine….especially a product such as life-saving medicine for your child.

People bring a lot of baggage with them when they reach the window of a kiosk and carry out a transaction. And perceived ability-to-pay is important but is not the only determinative of people’s choice. We understand very little about how poor people in remote rural Africa make consumer decisions, and even less on how they make decisions about purchasing “bio-” or “western” medicines. We need to understand more about this. And presenting a product that has been proven to be “in demand” by remote rural Zambians – people living in quite extreme poverty – suddenly lets people talk about “why?”

Kit Yamoyo, make no mistake, will never be the cheapest product out there. Clinic–based ORS (which is free if it’s in stock) is. Even traditional medicine is. But a Kit Yamoyo supplied by the private sector is not. So why do poor people buy it? It touches upon the broader issue of: “Why do poor people still utilize the private health sector even when the public sector is free?” Let’s understand this better. And not just reduce the lives of poor people to a purely economistic “do they have money or don’t they” argument. People’s lives – yes, even poor people’s lives – are infinitely richer than this.

So, we must both aggressively eliminate/bring costs down for the poorest people on the planet in order to achieve the greatest equity possible, while at the same time NOT making the mistake of reducing every consumer choice/decision that a poor person makes to one solely based on cost. Go live in a remote rural village in Africa for a couple of years like I did and you will see that even the very poorest of people, living in the most dire of conditions, seek, as best they can, the dignity of self-determination. I truly believe that affordability of essential medicines is, without a doubt, a human right, and that every individual on the planet should have the affordability barrier eliminated as a factor in his or her decision to seek healthcare.

Comments?

Back to the nuts and bolts of the trip, another significant outcome is that Dr Jesca Nsungwa-Sabiiti has asked CHAI for a presentation on the Kit Yamoyo at next week’s Diarrhoea & Pneumonia Coordination Committee so I will be working the Damien, CHAI’s Essential Child Medicines Programme Manager at office this morning before I leave.

I know that things move slowly and I know that I am the eternal optimist but I think Uganda will have their own Kit Yamoyo by the end of 2015 and they won’t need much support from ColaLife to achieve this . . . you heard it first here!

Thanks to everyone who made this possible. This afternoon I leave for India…

Thanks to Beth for checking the context of this blog post and contributing to it.

Comments

Thanks for the update on your trip, which sounds hugely positive from many different perspectives.

I was particularly interested in the discussions you had around price and value and wholeheartedly agree with the points made by Beth. I’d like to build on that by making a couple of comments.

The measure of “value” has to be related to sustainable health outcomes – the issue is one of delivering maximum outcomes at optimum levels of input – in other words, value for money. One also needs to recognise that there there may be limits imposed by affordability – the so-called ‘cost as an independent variable’ issue – but nonetheless level of outcome for money (not cost) is the measure that counts.

It occurs to me that the real input measure should be total cost of therapy at point of use/consumption. If that is true, then low-cost ORS on a shelf in a warehouse, or clinic, or persons home has no value until it is used – i.e. zero value for money – or infinite cost per unit of outcome. For example, if large sachets cannot be used efficiently – i.e. some of the content is wasted then this needs also to be included in the ‘cost’. On that basis, if for the sake of argument only half a large sachet was used and the rest wasted, then the real cost of the treatment dose might be regarded as doubled.

So there is real benefit in thinking about cost and value in end-to-end terms, across the entire ‘supply chain’ to point at which the therapy has had an effect. It may be that, on that basis, Kit Yamoyo is a lot more cost-effective that one might imagine if the only measure is cost of supply to a retailer or other provider.

This also highlights the importance of following through to ensure product is consumed effectively. The fact that in the UK £billions are spent on prescribed medicines that are never used by the intended patient (largely a behavioural issue) is a good illustration of this point and links back to my earlier point about end to end value.

Sorry for my lack of coherence here. I’m surrounded by screaming children. But I wanted to respond to Colin’s interesting and pertinent points made about “value for money” (and I should state outright: I’m not an economist, I’m a social anthropologist who has been working on issues related to access to health technologies for about 6 years…hence the reason I tend to focus, when thinking about “poor people,” less on the “poor” bit and more on the “people”).

Partnership for Maternal Newborn and Child Health (PMNCH) health economics team has recently been focusing on two elements related to the domestic financing of MNCH in LMICs: More Health for Money (I think this coincides with what Colin calls value for money) and More Money for Health (i.e. how to pay for all of this). I think ColaLife really addresses both ideas, by strongly emphasizing both demand- and supply-side issues of ORS/Zinc access.

On one hand, by focusing on demand side inefficiencies (waste of ORS solution, inaccurately measured ORS solution, lack of knowledge and inappropriate use of Zinc), the project has always been about how to get far “more health” out of ORS+Zinc therapy, than has previously been achieved. As such, I agree whole-heartedly with Colin that a most obvious next step would be to find someone who can help measure how much “more health” Kit Yamoyo achieves.

At the same time, partnerships with local manufacturers, capacity building for these partners, perhaps impact investment to help them get started (as well as a willingness to turn the entire project over to the manufacturing partner when the project is done…), addresses the “how do you pay for it” (More Money for Health) issue, i.e. Kit Yamoyo is sustained because the manufacturer sustains it, and the manufacturer sustains it because the manufacturer now knows he/she can sell it. Kit Yamoyo (hopefully!) achieves ‘more money for health” because the whole thing will eventually end up running itself without a donor or NGO having to pay for it. Another interesting next step might be to document from the manufacturer (Pharmanova) point of view, how over the next 2-3 years all this plays out for them.

Secondly, going back to the “cost” issue, I want to bring up something that Simon, Jane and I have discussed in the past, and which has also been addressed elsewhere, in other contexts (e.g. generating demand for maternal health services at the Matlab research site in Bangadesh).

Right now, its hard to assess the role of promoters and retailers in ensuring appropriate use. Training these people has been quite expensive (cost of materials, holding training events etc.). But the “More Health for Money” aspect of an anti-diarrhoea kit such as Kit Yamoyo might, in fact, be partly dependent on intensive health promotion. So its important to understand cost-effectiveness across several scenarios: a) with health promotion activities/retailer and promoter training; b) doing no promotion but training retailers; c) doing promoting but not training retailers; d) doing nothing…and just letting the kit enter the market (perhaps relying on overlap with other diarrhoea initiatives and activities carried out by other partners). In short, any study of cost-effectiveness is related not just to measuring the cost of components, manufacture and delivery of the kit against the subsequent health outcomes. It also has to consider the costs associated with education, information, communication and follow up. And potentially the costs of establishing the partnerships that are going to help ensure this IEC happens…because it may not necessarily be the area where ColaLife can or should add value, and others may have greater capacity to do this work.

I think my comment should have ended with following sentence (because it ended with another kind of controversial sentence that I made Simon delete ! 🙂 !): An access model should focus not only on affordability (can/will people pay for it?), but on availability (can someone who wants it get their hands on it?), acceptability (will people see it as a means by which to treat diarrhoea in the household? will clinicians refer patients to it?), utilization (will people use it correctly), and, last but not least, what Reich & Frost (2008) refer to as “architecture” (do the sorts of institutional relationships and partnerships that need to be in place to sustain all of the above actually exist, and are these relationships themselves sustainable?) (see http://www.accessbook.org/). The COTZ trial focused on all five of these pillars of access. And that is what attracted me to it.

I will stop here before my children draw blood! Thanks Colin for your insights!

Huge thanks to Beth and Colin for your insightful comments. I might have to express some of these in our final report on the trial (with your permission!) which is ‘coming soon’. And if I do, I will certainly clear it with you and credit appropriately 😉 This is what open-sourcing of expertise is all about. Keep the insights coming!
Jane

You make some excellent points and I particularly like your use of the phrase ‘Health for Money’ and the separation of that from the related issue of Money for Health.

I think all of the above stresses the importance of an end-to-end approach (similar to the notion of ‘care pathways’) – but where one end is the health – and picking up your anthropological perspective – and social outcomes. i.e. the child patient has overcome the bout of diarrhoea; the mother/carer and community, of which they form part, understand the linkage between the illness and the therapy (correct use of the entire Kit Yamoyo); and expect to use this therapy when the need arises in future (i.e. its use will in future be normal and expected behaviour).

It’s interesting to note that while we were beginning this particular discussion Simon was on his way to India to participate in a very similar series of discussions.

I need to go now but will return to this stuff with some reflections on the India Report.